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tv   Key Capitol Hill Hearings  CSPAN  September 10, 2016 2:00am-4:01am EDT

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september 11th on c-span, the c-span radio app, and now, a house hearing on laws
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that mandate equal coverage for physical and mental health care. mental health care providers testified about difficulties in implementing a federal health care parity law. this hearing of the house energy and subcommittee on health is an hour and 40 minutes. ladies and gentlemen, if you'll take your seats, we'll start. the subcommittee will come to order. before we begin, i want to make a note that members may be filtering in and out throughout the hearing. unfortunately, the condensed september session, there are a number of scheduling conflicts this morning. but we wanted to be sure to have this important hearing before congress recessed at the end of the month.
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with that being said, chair recognize himself for an opening statement. today's health subcommittee hearing will examine the federal mental health parity laws and regulations. in 2008, congress passed a bill requiring most group health plans to provide more generous coverage for treatment of mental illnesses comparable to what is provided for physical illnesses. this mental health parity and addiction equity act, mhpaea which followed the mental health parity act of 1996, the mhpa requires equivalence or parity in coverage of mental and physical ailments. parity means that insurers need to treat copayments, treatment limits, prior authorization for mental health, substance use disorder the same way they treat
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for physical health care. the mhpaea originally applied to group health plans and group health insurance coverage, and then was amended by the affordable care act to also apply to individual health insurance coverage as well as medicaid benchmark, and benchmark equivalent plans. with more than 11 million americans who suffer with severe mental illness such as schizophrenia, bipolar disorder, major depression, this issue is vitally important for individual patients as well as families seeking appropriate care for their loved ones. since there seems to be ongoing discussions or protections as envisioned in the mental health parity laws previously enacted, it is timely for this committee to consider ways to streamline the mental health parity system. title 8 of the helping families in mental crisis act authored by committee member tim murphy of my home state pennsylvania and
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bernice johnson of texas offers eight provision concerning mental health parity such as improved compliance guidance and disclosure support. of particular interest to our democratic committee members is a proposal by representative joe kennedy of massachusetts, hr 4276, the behavioral health coverage transparency act of 2015. and this bill offers one of the many approaches to modifying parity requirements. today we have three expert panelists who will provide testimony and answer questions on the strengths and challenges of mental health parity standards. and i look forward to the testimony today. to ambulance my time. >> thank you, mr. chairman. and to our witnesses today, we thank you. i want to thank the chairman for calling the hearing. and i want to thank all of my colleagues for the great work that we all did together as a
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team to pass that mental health reform package and through the house, get it through the house in july. and i think it was significant that both sides came together on what i see as a very important issue today as we talk with you all, i'm going to want to highlight some items pertaining to the zika virus. i do have tremendous concern about what we see happening here. "wall street journal" had an article, and i'd like to submit this for the record, mr. chairman, researchers in the fda now are mentioning that with the zika virus, we could potentially probably will see an uptick in mental illness, parkinson's, diseases of that nature, dementia, et cetera. we know that the virus is fast spreading, fast growing. i think 16,000 cases now in the u.s. and our territories. and i'm quite concerned about
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the parallels between the virus and some of the mental health issues that we have. so i do want to highlight that. and mr. chairman -- >> without objection, so ordered. >> i appreciate that and i yield back my time. >> is anyone seeking time? >> mr. chairman, i go to a local health care provider in the mental health space, john markley from centerstone, illinois. i asked him these very same questions. what can be done to be helpful. the federal government should use specific guidance to state regulators on plans on how to implement the federal parity law. identify parity violations and enforce the law in public and private insurance. the federal government should issue additional guidance requiring the transparency requirements and molding issuers and appropriate coverage and plan design. and robustly enforce
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requirements of the federal mental health substance youth disorder parity law perspectively during plan approval and retrospectively through complete investigations. and we'll probably hear some of that from the testimony from our panelists. and i appreciate the time of the chairman. i yield back. >> the chair thanks. i also have a question. a consent to submit the following letters from america's health insurance plans to the president's task force. a letter from the eating disorders coalition. a letter to congress from 43 organizations representing providers, professionals, patients, family members and consumers. the chair now recognizes ranking member of the subcommittee, mr. green. five minutes for opening statement. >> thank you, mr. chairman, for having this important hearing. and our witnesses, i thank each of you for taking your time out and being here this morning. for too long mental health and substance abuse care has been siloed from the rest of the health care system and stigmatized. perhaps the biggest barrier to accessing care has been higher cost, lack of coverage for
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mental health, and substance use care. to begin address, congress passed the mental health parity act in 1996. the law prohibited employers, sponsored group health plans from setting higher annual or lifetime dollar limits on mental health benefits and many other benefits. the paul wellstone and pete domenici addiction equity act in 2008 built on this first step and provided protections regarding your quality of coverage for medical and surgical benefits and mental health and substance use benefits. this was further strengthened by the affordable care act in 2010. while the progress has been made, there is much room for improvement. since mhpeaea was enacted in 2008, insufficient enforcement and compliance, spotty disclosure of medical manage information and other implementation barriers to accessing mental health and substance abuse services with the equivalency to physical
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health services has muted the promise of the law for many. today we'll be at hearing with witnesses from the current state of parity laws and on the ground enforcement. without strong enforcement of the parity law, millions of people continue to struggle to get health care they need. i look forward to learning more about this critical -- from california, doris matsui. >> thank you, mr. green. what we really want to do today is treat mental illness as a disease. and if afford it the same enterally intervention that we have. parity is designed to ensure that insurance companies cover mental health benefits the same way they cover physical health benefits. congress started this effort with the mental health parity act in 1996, and we have continued to build on it since then. we have made great strides with the affordable care act by
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allaying the concept that parity to more types of plans and more types of benefits and adding mental health and substance use disorder to the list of essential health benefits. yet we need to make sure that these laws are being applied and enforced consistently. we included provisions to include to strengthen the parity law and the mental health reform bill. this committee worked hard to pass before the august recess. i also support the ideas my league representative kennedy has put forth to take these provisions a step further. i look forward to hearing from the witnesses today. and what we can do moving forward to ensure that everyone has access to the treatments and service they need. i yield back to the ranking member. >> thank you. thank my colleague for her work. and again, the time has come now to actually enforce the mental health parity laws over the last 20 years as both the state legislator and a member of congress. i've watched how we've tried to improve it, but it has not been
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successful. so mr. chairman, i thank you for calling this hearing today. and again, hopefully if not this session in early next session, we can continue to work on making sure we provide the parity of mental health has with our physical illnesses and our insurance policies. and does anyone else want time from my side? >> chair? >> i yield back my time. >> chair, thanks. gentlemen now recognize the ranking member of the full committee. five minutes for your opening statement. >> i'm sorry. i just want to thank you, mr. chairman, and mr. green for this hearing on the state of mental health parity in america. because current mental health parity law requires that insurers treat mental health and substance use disorder care the same way they treat physical care and that includes copayments and prior authorizations. today more than 41 million adults have some form of mental
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illness. but in 2014, less than half of them received mental health care. and more than 20 million people over the age of 12 have a substance use disorder, but only 2.6 million received treatment at a specialty facility in 2014. perhaps this can be explained in part because the majority of americans do not know that there are mental health parity protections in current law. this congress we've had several important conversations on the challenges facing our mental health system, and we recently passed a bipartisan mental health bill in the house. and i'm pleased that we're here today to continue that work by having a more in-depth discussion on mental health parity. the last time we made major improvements to mental health parity laws was in 2010 when we passed the affordable care act. the aca expanded both parity protections and health insurance coverage making early treatment and treatment prevention services accessible to millions of americans. under the new aca all individual and small group insurance plans are mandated to cover mental health and substance abuse disorders as one of ten
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essential health benefits. in addition, the aca expanded parity protections for substance use disorder services to individual health plans and certain medicaid plans. so this essentially means that these plans must provide coverage for mental health and substance use disorder services at the same level as coverage for other medical service. so today i'm interested in hearing from our witnesses about how our current parity laws are being implemented and enforced. because without proper enforcement, those laws will not have the impact we hope for them to have. and finally, i'd like to thank congressman kennedy for his strong leadership on this topic and for requesting this hearing. he sponsored legislation this congress that contains important parity provisions that were not included in our house-passed mental health bill. it's clear that we can and should be doing more to ensure that americans are able to access necessary mental health and substance use disorder services. and i hope this hearing will shed some light on what steps we can take going forward. so i would like to yield the remainder of my time to
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congressman kennedy. >> i want to thank my -- excuse me -- thank the ranking member and the ranking member of the subcommittee, mr. green. i also want to thank chairman upton and chairman pitts for allowing us to have this hearing today. and for their leadership on mental health and continuing to make mental health parity a priority for this committee. i also want to thank mr. selig for his work and the work of health law advocates. it touches thousands of families and patients across massachusetts. it's a privilege having you representing our commonwealth today, sir. and for all the advocates throughout that have helped inform our efforts in this committee. without your support we wouldn't be where we are today. i thank you. when the house passed the bill in july, it was a need step forward in efforts to fix a deeply flawed system. but our work is far from over. because no matter how many providers we train, grant programs we fund, failure to insurance basic insurance coverage for those service means the vast majority of working and
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middle class families can't afford them. that's why i'm grateful for today's hearing. parity. the simple idea that substance use disorder and heart disease should be treated the same is the law. that's not what this debate is in fact about. but without proper enforcement and transparency, the law is little more than empty words. it is meaningless to the patients and families who need and deserve the access, the mental health parity act, the addiction equity act and the affordable care act were intended to guarantee. and that lack of enforcement and transparency has devastating consequences. i recently read a story of a mother whose son matt lost his life after an insurance company continually refused to cover long-term treatment for his substance use disorder. she wrote that she, quote, used to wish that matt had cancer. at least he would have received timely nonbiased treatment. beneath the heartbreaking stories and anecdotes are statistics to back them up. claims from mental health care are denied at nearly twice the rate for claims for physical
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health. 24 out of 25 insurance companies in california charged higher copays or coinsurance for mental health care than physical health care according to investigation by state regulators. guided by those stories and statistics, i introduced the behavioral health coverage transparency act to force insurers to disclose the rates and reasons for denials for mental health care while holding insurers accountable for any violations through random audits. it would create a portal where patients not only lodge complaints but learn more about her coverage option that lack of accessible information is a major roadblock to health care. my own legislative director, a health policy expert spent over two unsuccessful hours on the phone with her insurance company last week trying to get the medical necessity documents she is entitled to by law, and still has yet to receive. parity is a promise we made to millions of americans who suffer from mental illness. it is their lifeline. we haven't yet made good on that promise. we are allowing insurers to hide
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behind a curtain of appropriate tear information in a brauj language of denials. unless and until this committee becomes serious about ensuring parity. in this body, those reforms begin and in this committee room and i hope that my colleagues will join me for calling for parity to be included in any conference report that reaches the president's desk. thank you. i yield back. >> thank you. the gentleman yields back. all opening statements have been concluded. and all members have the opportunity to submit statements for the record. i like to introduce the panel we have before us today. first i'll introduce all three. and then their opening statements. pamela greenburg, 39 and ceo, association for behavior health and wellness. dr. michael tringale. and matt selig, executive director, health law advocates. thank you for coming today.
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and you will all each have five minutes to summarize your testimony. and your written testimony will be placed in the record. if you notice the lights, you'll get a yellow light when you get close. and a red light it would be time to sum up if you haven't concluded at that point. and i'll begin with recognizing ms. greenburg for five minutes. >> good morning, vice vary man guthrie, ranking member green and distinguished members of the subcommittee. thank you for the opportunity to testify before you today. my name is pamela greenberg. and for last 18 years, i have served as the president and ceo for the organization for behavioral health and wellness. abhw is an association of the nation's leading specialty behavior health care companies. these companies provide an array of behavioral health care services to over 170 million people in both the public and private sectors. since its inception in 1994, abhw has actively supported mental health and addiction parity. and we believe that it is important to diagnosis and treat mental health and substance use disorders at an early stage. abhw is an orange 'nam member
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and at one point a chair for coalition and fairness coverage. in my testimonily provide a brief overview, discuss compliance and discuss next steps as we continue to move forward. as members have already said it expands on the mental health parity act of 1996 that created parity for annual lifetime limits between mental health and physical health limits. but it applies to plans with over 50 employees. it does not mandate coverage for mental health and substance use disorders. the law and regulations state that financial treatment and nonquantitative treatment limits can be no more restrictive than those on the physical side. additionally, the law requires the disclosure of medical necessity criteria and the reason for denial. the law also provides that if out of network services are available on the physical health side, they must also be available on the mental health side. it's important to note that parity was not intended to be the panacea for all mental health and addiction issues. for example, parity does not
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address our work for shortage issues, nor does it look at the quality of care that is being provided. the affordable care act extended it to individual markets small group and qualified health plans. parity also applies in medicaid and try care. our companies have had numerous meetings with the regulators to help us better understand and operationalize the regulations. our member companies have teams of dozens of people from multiple departments working diligently to exchange information and perform the required analyses. the analyses are complex. for example, in order to complete the parity analysis, abhw member companies review a variety of documents including summary plan documents, medical necessity criteria and medical management program descriptions. and then they document the underlying processes, strategies, evidentiary standards and other factors considered by the plan. and then they review these findings with the organization's legal team and recommend any needed changes.
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our members have been audited for parity compliance at both state and federal levels. the dol and nhss have been enforcing audits. in its january 2016 report to congress, the dol reported since october 2010, they have conducted 1,515 mpea investigations and cited 171 violations. hhs has also received complaints and to date has been able to avoid litigation by resolving the issues through voluntary changes through the health plans. regulating agencies have also issued multiple sets of frequently asked questions and fact sheets. this year president obama established a white house mental health and substance use disorder parity task force that is going -- that is working to improve parity. i ask that our comment letter to the task force be included in the record. to say that parity is not being implement and enforced is a misrepresentation. it is important to recognize the strides that have been made and work together to develop best
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practices to move forward. we have to make sure that we are not so rigid with our implementation of parity that we end up ignoring the differences that exist between behavioral and physical health. and as a result, compromise quality care. further discussion is needed on the disclosure issue. transparency and disclosure of information to consumers is important. but we also have to keep in mind the results of a new research paper that found that 86% of participants could not define deductible copay insurance and out of pocket maximum in a multiple choice questionnaire. recent legislative attention in the area of disclosure has contributed to the issuance of additional guidance. there needs to be a more concise option for consumers to understand how their health plan has parity without burying them with hundreds of documents. some ideas to consider is the development of a document that would explain how they have performed the parity analysis. another idea is to provide examples that would include
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scenarios of questions a consumer might ask, and then also the documents they may want to request to answer those questions. a third area that needs additional attention is education to all stakeholders as to what is and isn't included in parity. hhs is working with states and the national association of insurance commissioners. dol has issued a compliance assistance guide and a check sheet to assist employers. and samsa has information on their website. if i could just finish up, our members are faced with disparate and sometimes incorrect interpretations of state agencies enforcing the federal law, and we would like to see more consistent enforcement. and finally, if i could just bring two issues to your attention, and those are the disclosure of substance use records related to 42 cfr in part ii. and meaningful use incentives from behavioral health providers. we hope the committee considers
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those at a later date. thank you for the opportunity to testify today. and i look forward to ongoing discussion as we move forward. >> thank you for testifying. dr. tringale, you are recognized for five minutes. >> thank you, vice-chairman guthrie, ranking member green and all the committee members. i'm michael tringale. i'm a practicing psychiatrist and have been really actively involved in kind of efforts we've been doing to make things better. i'm very involved in quality improvement leading initiatives to improve depression outcomes, outpatient, reduce admissions for people coming from psych units, trying to lengthen the life span of folks with serious mental health issues in our state. just work hard on that. i'm from an integrated organization where there is health plan medical group of about 1800 docs, hospitals. the health plan covers 1.63 million lives. i know we're all working hard to
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try to produce parrot. >> the both clinicians like me and administrators who know the details of the policy in a way i don't to try to make sure we really understand and are fully implementing it. i want to talk about some of the efforts that we're doing in the real world at the ground level to try to make things better. one initiative that we've been very successful with our public radio station and nami and other organizations to reduce shame there is so much shame involved that if you can start conversations, people would be willing to listen to their primary care doc or bring it up and get going. for our members we measure closely and look for improvements. we're at a 96 member satisfaction either very satisfied or satisfied for access to pay for health resources in our system. we've come up with ways we've offered we think it's so good to our employees as well as all of our poyshs whether they have our
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health plan or not, or they can go online in our internet and participate in cognitive behavioral therapy treatment program at their own pace to improve depression and anxiety care. we've created an algorithm based on claims to look at who is at high risk to not do well in the next six months. i can give you an example of one of my patients who is a 44-year-old woman, married, three kids, lives in the burbs. started seeing me as an outpatient for depression and anxiety. and despite my best efforts, wasn't getting better. and then i realized she was probably abusing substances. and then when i talked to her she wasn't willing or interested to do treatment. she got worse. she ended up getting drunk, passed out while smoking in bed. her house burned down. thankfully her kids and husband got out safely. but she had between 20 and 30% burns. got hospitalized in a burn unit in a hospital that is not integrated with our system, but our health planet work. was there for about three week, came out and still was even
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worse than before. she was still depressed, anxious. she had started abusing opiates because she had pain now as well as drinking. and we had a health care coordinator that was working with this person, and her job is to reach out and talk to all the various people and places involved in her care. she reached out to the hospital and found out that the patient was actively suicidal there. and had been civilly committed and was under court order to go and participate psychiatric care supposedly under my direction. she had not filled out a lease of information, lied to me about it. but this care coordinator discovered this. and all of the sudden i could have a real honest discussion with her. and we got her into a dual diagnosis treatment facility. it's about two years later now and she is still off opiates and alcohol. not really depressed. still struggles with anxiety. her life has turned around. it was because of this
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extraordinary care coordination that spanned different levels of care and systems of care that probably saved her life. i agree with the workforce shortage. you know, we find that we're doing a lot of things to try and put psychiatrists and therapists in our primary care clinics. and there is a shortage of health psychologists there is a short of psychiatrists. we've been taking efforts and partnership with nami to do extra training to get physicians assistants and nurse practitioners and clinical nurse specialists to increase our pool of subscribers. we're working hard to improve the flow of psychiatric patients. we have patients accumulating and people on psych units who can't get out waiting to get into group homes and residential treatment centers. we need to partner with the counties and states who have responsibility for those things. they have budget limitations and they're not enough. i see i'm going to run out of time. one other thing we've been trying to work on but it's hard is payment reform so that we can flow our money to pay for outcomes and can then afford to have care managers in our
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clinics reaching out to patients between visits, reaching out to make sure it's been so long, you haven't rechecked. how you doing with your depression. and making sure they come in and that they're getting into remission. and it requires partnerships in ways that i don't think is usually talked about. that's viewed as a public sector. we're viewed as a private sector. and we've got to work together. and when we do that, we can sort of get patients out of the hospital sooner into group homes. and there are eds who are overflowing our safe space, our lock space for psych patients, we can get them into the in-patient unit. and a lot of what we're doing really involves kind of taking disparate partners and agreeing to a vision and then trying to work together. but it's very hard because the funding streams are not braided. i see i'm going to be out of time pretty shortly. >> if you could just summarize. i'll be a little lenient. but if you could summarize. >> so, you know, in a lot of ways, there are also new models of care where we're trying to
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really truly integrate behavioral health resources with health plan resources. both delivery system. and this care coordination is another way of doing this. we have programs where if i have my patient and they don't get their refills for their anti-psychotics, i'll hear about it because of the health plan feeding that data to me. the patient hears about it. well can reach out and try to capture them so they don't get psychotic and really struggle. we do the same thing with depressed patients. and it really helps a lot. we have initiatives where we have people like me going or telemedicine going to primary care clinics, primary care docs will talk about their depressed patients and issues and struggles. i'll give advice. and for two hours a week i can sort of leverage what primary care is doing for about 100 patients. leverage the shortage of psychiatrists. >> we have a chance to address some of this during our question and answer. we appreciate very much. thank you for that testimony. it's very informative. mr. selig, you're rooged for five minutes. >> thank you very much for the opportunity to appear before you
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today as you examine the parity law and regulation. i am grateful that you involve have convened this hearing. my name is -- >> request to pull the mic closer. >> i'm sorry. my name is matt seal lick, and i'm the executive director of health law advocates. it's a public interest law firm with the mission to improve access to health care for low income massachusetts residents. we provide prebono legal assistance who have been denied mental health care. we try to improve access to mental health and substance use disorders care by making the protections of the parity laws both federal and state a reality for those we represent. hla represents occasional 70 patients each year who have been denied. this work gives us an upclose look at the problems constitutionals have when trying to access treatment. we also see how current parity laws and regulations are implement and enforced. hla work versus closely with other advocates across the country with a strong interest in parity. as a result, we have a broader
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perspective on the insurance problems people face when they need treatment and how the parity laws are or are not addressing the problems. while we and others believe there is much more important work still needed to achieve true parrot. >> the i want to express hla's true appreciation to you as well as state regulators across the country who have made significant gains achieving parity already. we're particularly gratified the airporty has been very much a bipartisan issue in congress, and that has been true in massachusetts as well. in health law advocates' experience with clients, individuals have more difficulty accessing mental health and substance use care because of barriers created by many insurers. our assessment corresponds with the national alliance on mental illness report last year which found that twice as many families reported that a member of their family was denied coverage for mental health care as for general medical care. our lawyers have identified certain types of types that are particularly susceptible to coverage deniles. i'll mention some. residential treat for substance
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abuse, eating disorders, applied behavioral analysis for autism spectrum disorder, medication-assisted treatment and outpatient psycho therapy more than once per week. hla represents clients of all ages, but we devote particular resources to helping children access care. over the years, we have seen families struggle to obtain coverage for kids, especially for services such as neuropsychological evaluations, wraparound community-based care, autism services and step-down care from acute treatment. we've witnessed practices frustrate treatment for care. for example we have seen repeated early terminations of coverage for treatment regardless of the severity of our clients' symptoms. doctors being required to titrate medication assisted treatment as a condition of coverage even when mandatory titration is not the standard of care. treatment providers subject to onerous requirements to justify care, and termination of service based on age or lack of parental participation. these examples involve clients
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who are fortunate enough to have at least connected with a provider. we also represent clients of all ages, but particularly children who have great difficulty finding a qualified and appropriate provider in their insurer's network. in closing, i wish to offer a few recommendations to improve on current parity laws and their implementation. we strongly support hr 4276, congressman kennedy's behavioral health coverage transparency act there is no question we need greater disclosure of information by insurers. detailed information about how plans ensure that claims are treated equitably and the standards used to evaluate the medical necessity of treatment should be made public and written in language consumers can understand there should also be greater enforcement including enhanced penalties of requirements to provide detailed information to members about the basis for coverage denials and compare information on medical management and physical conditions. when hla requests this information on behalf of our clients, we rarely receive it. this prevents us from determining whether our clients' parity rights have been violated. an exclusive right of action would allow consumers to enforce this right themselves.
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consumers should also have access to an toes use access for filing complaints when their coverage has been violated. this would help consumers access the treatment they need and identify trends and noncompliance. the complaint process and consumers rights under the parity law should be broadly promoted by government agencies to increase understanding among consumers. the federal government should also assist carriers' compliance by publicizing and continually updating its adjudication of parity complaints to create an administrative common law for what constitutes a violation of the parity law. neither insurers nor their members should have to guess what treatment limitation practices are legal. finally, rerecommend that federal and state agencies conduct audits. these inquiries and other forms will serve as a check on self reporting by plans and identify problems where federal or state enforcement is needed. more enforcement is needed. that targeted enforcement will ensure that parity is not only the law of the land but a
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reality for people suffering with mental illness and addiction. thank you again very much for the chance to testify. >> thank you very much. i want to thank each witness for your testimony. and i will begin the questions and recognize myself for five minutes for that purpose. as chairman pitts discussed during his opening remarks, there have been continued discussion on safeguards envisioned in previously enacted mental health parity laws. ms. greenberg, one of the most recent documents abhw published is a letter in response to the president's task force. he urged the administration's working group to engage with stakeholders on clinical differences, additional tools for states, release of identified information, disclosure guidance and parity confidentiality rules. i would like to focus on the clinical disclosure and confidentiality rules. in this letter you write, and i quote, parity is important, but so is quality. we have to make sure we don't end up compromising on quality care of consumers, unquote.
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please help me better understand how political autonomy to achieve improved quality outcomes in caring for patients with mental health disorders can be repeated by burden some or better yet one size fits all regulations. >> thank you, congressman, for that question. i think that our concern as we've moved forward with parity implication is we have behavior health, and we have medical. and there are some things that are more clear-cut like the copayments and the coinsurance and things like that. but then there are other things about the treatment that is needed or when you check in with a provider to see how the treatment is going. and those are things that differ based on illness. and they're not so cookie-cutter that you say oh, exactly what you're doing on the medical side should be the same thing that's done on the behavior health side. and we would just like to see some flexibility within the parameters of clinical
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guidelines. so it wouldn't just be because we say we should do it this way, then it's okay. but the clinical guidelines may justify a difference in some areas on behavior health. and that language was included in the initial interim final rule. and then was deleted in the final rule. so i think just recognizing that there are some differences that do exist. and when clinically appropriate, those should be aloud. >> dr. tra in gle, would you like to comment? >> i can't comment on the details of the law. but i know clinically all the time we're trying to improve talking to primary care dox, seeing their lab results, making sure they can see what we're doing. and in some sense, one of the things mentioned in the prelude had to do with chemical dependency. we're struggling in our system with ed docs not seeing what meds is going on or what is going on in outpatient clinics
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and overmedicating people because we're not sharing some of that data with each other. it's just really important to be able to talk together. it's an interesting place where stigma plays out. we have primary care docs that in some sense will kind of be afraid to talk about somebody is depressed, you know. and shy away from it. but if they can see that we've talked about it because we have a shared electronic medical record that. >> know it's okay. all of the sudden they can help us follow up and they can help us measure are they getting better or not. >> okay, thank you. let me get to my next question. ms. greenberg, you note that certain transparency in disclosure efforts may be well-intentioned but overwhelmed with thousands of pages of information. but other patients have asked for even more access to benefits details would. you please share a more efficient and effective way to help patients understand parity fairness? >> sure. the documentation that is available to patients or should
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be made available to patients includes a lot of information that health plans are using either their analyses or the documents they had to look at to get to what parity should include. and while those documents are available, we'd also like to see some type of summary of the analysis instead of -- our concern is if we hand a patient a box or two of documents that will overwhelm them and also they're very technical. and it will be a little bit difficult to go through. so if we can talk about a uniform analyses that people would hand out first to explain to patients how parity was determined. and then kind golf from there as more documents are needed, or provide -- and/or provide care to patients as to what documents are appropriate to ask for their situation, not that they couldn't have more, but that at least at first they're getting just the documents that they need. >> okay. you also -- in the coordination that dr. trangle is talking
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about, our committee is really looking at coordination. we know that's important. in regard to substance use disorders, you comment that multiple signed patient authorizations are necessary to achieve true coordination. how does this limit quality of care? and then mr. selig, would you comment on the fact there are so many multiple signed documentation. is that a wall that the federal government should try to remove? actually, i'm out of time. do about -- i don't want to go. >> clarify, which signed documentations you're referring to? >> i get into it, i'm going to really get into it. i'll put that in the record. we'll give you a question for the record. otherwise it's going to take longer. votes are going to come some time mid morning i understand. so i will recognize that concludes my questions. i recognize the ranking member, mr. green for five minutes. >> thank you, mr. chairman. millions of americans, one in five have a mental illness. one in ten americans have a substance disorder in their
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lifetime. and 75% of them will not seek treatment. the lives of these individuals and their families and their communities will be significantly changed for the better with access to treatment they need. congress did our part. we passed a parity law requiring health plans and medicaid, medicare and the private market to cover mental health and substance use treatment to the same extent as they do medical and surgical service. we passed the affordable care act for expanded access to health coverage. however, without strong enforcement of the parity law, millions of people continue to struggle to get the health care they need. as a legal advocate, you're well aware of the importance of strong parity implementation enforcement. i'm sure you know how confusing insurance benefits it is and how hard it is to fight to get coverage you need especially when you're sick and need it the most. my first question is how hard is it for consumers to get the information they need in order to figure out whether they're insurer is meeting the requirements of parity?
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>> well, it can be very difficult, mr. green. as i mentioned in my statement when we're working with consumers who have been denied coverage. and they try to request information from their plan explaining why the service has been denied and providing the backup documentation comparing the medical management techniques for mental health and physical health, it's documents that really are rarely provided. and i recall mr. kennedy mentioning a member of his staff having the same experience. so it's very difficult to get that information typically. it's clearly requested by our team members at hla, and we don't get it. that being said, that information is difficult to understand.
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and we would favor information being made much clearer for the consumer. i think having boxes of information that indicate the process for determining how to -- when services are covered not only is complicated, but it also i think speaks to the extreme scrutiny that services are given when people are trying to get coverage for them. so we would definitely favor clear information be given to consumers. and also clear information on where people can get help if they don't feel equipped to try to understand the materials that they're given. as congressman kennedy's legislation provides a central portal where people can go and indicate that they feel as if they have been generally
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speaking unjustly denied coverage for care, and maybe they don't feel equipped to go through the documents and do the parity analysis themselves. but have an agency look at that complaint for them in a systematic and general and uniform way. >> and i know with our mental health bill we passed that's still in the senate, we didn't put that provision from representative kennedy in, but it's one we intend to do. since 2010, we know there are only 140 cases in which the federal department of labor has found parity violations. it seems unlikely that the parity has been implemented so comprehensively nationwide that there are only 140 violations. what steps can we take to ensure the law is fully enforced? >> well, thank you for that question. i would say that -- i would say several things. and many of them are embodied in congressman kennedy's bill, which i think is on the mark in many ways.
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we do feel like federal reporting requirements for health plans are important for health plans to be required to demonstrate how they're complying with parity and have that information public. we also think that random audits of health plans are important as a check on the self-reporting that insurance companies do. we also again believe strongly that there must be a simplified consumer complaint process and much greater public education that will help people understand what their rights are under the parity law and how to vindicate those rights and understand when a denial is inappropriate or maybe when it doesn't violate parity. i also support some of the provisions for sure in the legislation that the committee did pass, the compliance program
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guidance document that was included in that legislation. i think would provide a very valuable as i said in my opening statement kind of common law record of how the government has interpreted certain limits by health plans to give health plans and insurers a greater understanding of what our appropriate denials and what aren't. >> thank you. we're out of time. we even have problems with the physical health. because i have folks who think they have insurance and they show up at the hospital that's on their network, and all of the sudden they find out now days the practice of medicine there are different providers that are not part of that system. so when they leave they find out they're out of network. so it's confusing both the mental side, probably worse than the physical side. but we have those problems there. thank you. >> thanks. i'm going to try to stick to the five minutes as much as possible so we can get more questions in before there is actually a memorial service for 9/11 coming
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up this morning as well. dr. bucshon from indiana, you're recognized for five minutes. >> thank you. first i'd like to outline the problem. and it goes across all socio-economic statuses. i have a high school friend in my class who recently died at age 54. she had schizophrenia. their life expectancy is shortened. she had two children, and her husband divorced her and changed the children's names, and she ended up on the street because of really probably a multitude of factors. but one of those was her ability to get treatment. i also had a high school friend who came home for christmas break in college and broke up with his girlfriend. and a couple weeks later committed suicide at college, no other indication. the question in my mind is on college campuses, was there any indication that he was struggling. and that's true because my son, one of his fraternity brothers
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who graduated in may, and who had a job, just committed suicide at age 22. so this is really something we need to address. 22 veterans a week we're losing. i just wanted to outline the problem. as we all know. but for the record. and it is important that most -- to know that most mental health patients have other medical issues. in indiana, there are a couple of centers close to my district, centerstone in bloomington, hamilton center in terre haute that coordinate both traditional medical problems and mental health related issues including substance abuse disorder. so dr.
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diabetes, congestive heart failure, these are chronic problems. why in i think we all know probably the answer, but in your experience, why are we still struggling to be able to have parody in how people are treat because they happen to have a mental health issue? >> the tradition in medicine is to get things dialled up. some of the examples you mentioned -- diabetes, cardiovascular disease, heart failure has a significantly increased incidence of depression. if somebody has an ami and they are depressed and you don't recognize it, they'll have higher mortality. not because of the physiology. because they don't do their cardiac rehab. we need to screen for depression throughout all of primary care and make sure that for those that are screening positive we follow-up. ideally, you follow-up in
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primary care clinics where you don't have to get somebody to get over their own stigma and go to a more embarrassing place. you need to be able to virtually talk to the primary care docs and help them with advice, consults, and things like that. >> maybe you could help because you're involved in trying to help people get healthy. i'm still for years i've had this issue. they clearly had mental health issues. i diagnosed a number of people who were bipolar and depressed and everything and had a hard time getting -- there's a physician shortage, which we can address. why -- what in your mind -- what's your opinion why -- what's the impotus for difficulty getting coverage for say depression versus diabetes? it doesn't make sense really. do you have insight into that?
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>> well -- there's a parody law where it has been hard to implement. first of all, there's a patchwork of agencies that have to enforce the laws. we have the federal government, which directly enforces it with self-insured plans and also can provide guidance to state agencies and then you have 50 state agencies, division of insurance, and also medicaid office that is also have to enforce the law in all different ways. there's a patchwork of interpretations of the law. >> i guess the question is why would you need to have to interpret it? why do you need a parody in the first place? you see what i'm trying to get at? i don't know if we can answer that question today. >> i think -- if you don't mind for a second, i think part of the issue too is that there's a great stigma associated with mental health and addiction, and so we have treated typically mental health and addiction in
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our health care system differently than behavior health it. that's not the right answer or the right thing to do, but people are afraid to talk about their mental health and addiction for fear have being os sized. >> we'll have to get more questions in. hopefully have you the opportunity to answer some other questions moving forward. i like to recognize -- from california. >> thank you very much. i like to thank all the witnesses for being here today. >> it stems from the fact that there are different federal and state agencies responsible for overseeing and enforcing the parody law. this patchwork is a little bit of the nature of the game. the federal law says the standard and states could make more strict parody laws have california does, and states are also responsible in large part for making the rules for their own medicaid programs. mr. selig, can you give ab
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overview of the patchwork of state and federal enforcing agencies? >> i'll pick up a little bit of what i was just speaking about and try to do it quickly. there is a patchwork of enforcement agencies that enforce the parody law. you start with the federal government, which enforces the law for self-insured plans directly because those aren't under the regulatory perview of the states. each state has a division of insurance and an office of medicaid that enforces the law for those prospective plans. you also have the tri-care agency, also as ms. greenburg indicated, has a separate enforcement mechanism too. there are several different agencies that have responsibility for making sure the parody law is implemented and enforced. >> okay. well, because much of the enforcement tends to be at state level, especially for medicaid, it follows the states you learn from one another about best practices to insure consistency
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for consumers. samsa put out a report regarding best practices from seven states. for example, california insurance commissioner's office worked closely with california's exchange recovery california to design benefits under the parody law. >> there's interagency coordination across the country. >> sure, yes, the samsa docum t document -- >> i think the best practices is one of the most helpful ways to assist with parody implementation, and it's one of the other things that has been done as mentioned by all of us. the sharing of deidentified information. whether it be a problem that's found or something positive that's found by any of the
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agencies that are suggested that are doing the implementation. if they can let people know, this is the problem they found, and this is how it should have been treated or this is how the change was made to become parody compliant. or this is an instant where the plan is parody compliant, and these are the things that they're doing that we, the auditors, have found helpful. i think that information and those best practices are in some cases unfortunately worse practices would be helpful to us. >> how can we encourage more sharing information at a level where actually things get done? >> i think to talk -- reports like the samsa report to talk with states and encourage them to release the information and also to talk to the federal agencies to encourage them to share that information. >> thank you. there are up to 30 million americans experiencing eating disorders during their
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lifetimes. however, one in ten of these americans will receive treatment due to a lack of early identification and treatment coverage. you know, the paul wellstone and pete mental health parody and addiction equity act are designed to health insurance plans covering mental disorders and substance abuse disorders will provide the same favorable level of coverage as they would for medical surgical benefits. since the law has been finalized we see that there are still gaps in coverage. especially for people with eating disorders. with my colleague congressman lance, we led the efforts to include provisions to clarify coverage of eating disorders benefits, including residential treatment within mental health bill that passed the house before the august recess. in your experience, what is your understanding of how private health insurance contracts handle eating disorders? >> thanks for the question. thanks for the question. i think it's a great one. as my organization has grown, we
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combined with another organization, and we now own something called melrose eating disorder center. our organization is really intent upon trying to simultaneously improve the measure of the quality patient satisfaction and making it more affordable. as we kind of integrated this eating disorder place into a hospital into our system, we look at it from all different directions. both the quality, were they measuring outcomes they weren't. what was the expense? and much more intensive. it helped us reduce the length of days for inpatient. we created more outpatient resources. ultimately people are in care longer, but it's at less expensive levels of care. the cost has gone down, and the
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outcomes have gone up. >> thank you. >> you might want to say more of that to the record. thank you very much. mr. colins of new york. five minutes. >> thank you, mr. chairman. if you could speak just -- when i ask you a question, i'm going to maybe four inches from the mike. that's how sensitive these are. i want to thank the witnesses for coming, and i don't think there's a family in america that's not impacted by mental health at one stage or another and it's such a multi-facetted problem. unlike some traditional medical issues, i actually believe mental health is almost individualized to so many contributing factors. it's even -- it's hard to take six patients that may seem that it's all the same thing. i think this is a useful hearing to deep dive what's going on, how we can do better. just as a point of interest. my district includes the only
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veteran suicide center in the united states. every veteran who would have that unfortunate urge to commit suicide when they call in, they end up at a call center in new york. i spent a significant amount of time there talking to those who are answering the phone calls and it just became clear that the problems range from opiod abuse to ptsd and then ptsd leading to more opiod abuse. it's such a tragic thing that's going on in this country. appreciate all your testimony. i also know there's a balance between state regulations, federal regulations, more regulations that we have to address. dr., i'll just maybe ask my first question to you. as a clinician, says would more federal rules, more federal disclosures and more federal audits, because that's what we are here in the federal government, would this help in any way streamline care or as a
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clinician do you feel that more regulations at the federal level would potentially burden a system that's already pretty highly regulated as mr. selig pointed out? >> let me try and answer that. i almost feel like i am living in parallel universes. >> the patient was chronically depressed, and it was manic and having thought disorder. we talked about what do we need to do? there was not necessarily a clear suicidal thought. a little vague thought about a bridge. then the discussion was does this person need to be in an i inpatient unit, which means being locked up and much more
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restricted? do they need to continue to see somebody once a week? no. ultimately we came up with the idea that this person should go to a partial hospital program where they see a psychiatrist every day and get started on an anti-psychotic, talk about suicide, make sure they were safe, and it was not all or nothing. you know? you need to have some checks and balances in people that are making their recommendations, know what the resources are, and what's the right care at the right level of care at the right time. we have similar checks and balances that we struggle with. somebody came to me and said i read about kettamine, and i know it works for depression skpirks want you to change -- our depression scores showed she was getting better, but not fast enough for her. she said i want you to order it, and i want the health plan to pay for it. this doesn't even go to the health plan review. i said i'm up on this literature, and there's a number of individual studies showing rapid response for depression, but it doesn't last. as soon as you stop getting the iv, you get depressed again. it's not a good solution long-term. you know, how do you have checks and balances to make those decisions and not have people like primary care docs who don't
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necessarily know all the details saying this is what i'm recommending, but somebody with more knowledge is involved and gets the right care at the right time for the patient? it's a separate issue. more is not always better. it's what you share. what you communicate. >> yeah. thank you. i guess let me ask you a similar question. there are so many state enforcement laws as represented to. >> in trmgz of education and what are the questions of an he enforcer, no matter where they sit should be asking to determine whether or not a plan is parody compliant.
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that would be very helpful. i don't know that it has to be legislative. i think the regulators are working to get there. >> yeah. my time is expired. i want to just thank all the witnesses. this is such a complicated issue. thank representative kennedy for asking that we hold this hearing. i think it's being useful. >> thanks for that. >> yield back. >> appreciate it, mr. kennedy, from massachusetts. you are recognized for five minutes. >> a couple of quick points here. first i want to thank you again for your time and the work on behalf of patients and their families. we here time and again we talk about patients who struggle to get access to the care that they need, and in your experience what's the greatest barrier to that care, and is it insufficient reimbursements, inadequate networks, shortage of suppliers, and we'll start there. >> thank you, mr. kennedy, very much.
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thank you for your very hard work. >> work force shortages, which has been mentioned today. >> can i push you on that one? i would like to just ask -- just to -- the timing is brief. >> yep. >> given the restrictions here. all of you have mentioned work force shortages. your testimony -- you went into this in some detail. programs that you put forth, loan forgiveness, reimbursement rates. would you support movement on all of those to address the work force shortage issue? >> would we support -- yes. >> yes. >> absolutely. >> 100%. absolutely loan forgiveness and better reimbursement would be
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critical for that. >> great. >> mr. greenburg, my cousin patrick served in the house, and you passed a groundbreaking adult parody law. there was early support for that legislation and for -- years later we worked to try to implement the spirit in a letter of the law, and the final rule for adult parody clearly indicates that it requires the criteria for planned medical necessity determinations with respect to mental health or sbas abuse -- be made to any including from my legislative director who spent two hours on the phone with an insurance company whose folks representatives had no idea what she was talking about. that information doesn't exist, and she said you're not in compliance with the federal -- i can go through the minute by
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minute read-out. i understand the fact that this is very complex. most experts in this room will struggle with that level of complexity. the complexity. >> to make sure the information is available, and to make sure the parody is being complied with. if the issue is complexity, and it's been ten years since the law is passed, can't we find a way to simplify some of the information so consumers can digest it? >> yes. i would like to work with you and others that are interested in this topic to try to find what is that kind of concise document that we can give out, and i think that would help insurers understand, okay, what are the components that need -- that should and need to be given and also help with consumers
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because they would have it in an understandable document. i will say i agree with you the medical necessity criteria should be disclosed. that is part of the law. many of our member companies have it up on their website, and in that specific situation, still an issue i would like to help with that as well. >> great. that was one specific company. you know, there's obviously many plans and challenges out there. one of the challenges that we also hear over and over and over again is that there should be a central clearinghouse for essentially a database for issues and complaints that arise so that information, again, can come from a centralized location so that regulators, advocates, patients can understand what services they can get, what is covered, what isn't gin the complexity of this law, and the challenges for it. that is part of what's contemplated. i love to get your thoughts on, again, how we can insure that the transparency requirements --
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we shine a greater light on that transparency. >> we do support the idea of a consumer portal that i know is in your legislation and also the -- we would say, and i think you do as well, de-identified information and people always remind me to say not just the problems, but also deidentified, but show the good things that have happened and where there have been success stories and parody because there are some of those as well. i don't know, congressmen, whether legislation is necessary to do this. i think, you know, that strict and strong conversations with the regulators, and we've as a result of the attention you have brought to this issue guidance issues in the last few months -- more guidance issued on the disclosure topics. you are setting a sunlight on it. >> thanks. we're going to -- i hate to -- you got other things? >> i have a number of documents i would like to introduce for the record, and i appreciate the time. a letter from a number of organizations from former representative patrick kennedy,
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and a letter from other advocacy recommendations. >> with that objection, so noted. i'll compliment you on your passing of this as well. mr . >> my time to representative kennedy. >> you're a good man. let's focus a little bit because i have a couple more minutes. the reimbursement issues. my understanding -- again, mr. selig, we can start there. >> you know, i know i read an article that came out just this past week. i think it was in jama where they talked about -- it did document some variability there as well as sort of variability
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and how many psychiatrists were participating and in what plans. so i know there's data out there nationally of how that plays out. in our area i don't think we necessarily -- what we have are psychiatrists that opt out of the system totally. >> generally speaking, looking at reimbursement rates, private slurns generally reimburses higher than medicare. one of the challenges that we have faced, even over the course of the past couple of years, is that we've been searching for information about medicaid's reimbursement rates for mental health services. it's a joint federal-state program. they don't compile a database of what the reimbursements are. mr. greenberg, is there some
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information that given the companies that you represent and the scope that you -- the number of states that your company has practiced in, that data clearly exists. it's just that the federal government doesn't have access to it because a conversation as they've indicated the nature of the joint federal state program. >> i would be happy to try to be honest if it's ant -- the question that we asked. >> we've heard some of the
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challenges with parody, but we've heard from all of you today the struggles with work force. if we're looking at struggles with work force and medicaid is a largest payer of mental health services in this country, that if we're not looking at reimbursement rates as one of the drivers for work force shortage, then it's tough to address that issue for work force if we're not looking at the compensation mechanisms for the professionals. >> yes. >> you want me to keep going? >> sure. great. >> so if i can continue, insurance companies often say that they're making efforts to comply with the law, and your testimony with mental health parody, your testimony -- why is it that given a good faith effort to comply with the law, why is it that ten years on we are still struggling with the actual receipt of that
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information, and they're struggling with patients being able to gain access to the care that they need when they need it, and even understand what services are available to them.
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>> what format are you looking for that information. as i mentioned in the at the time, we've had dozens of meetings with regulators. there are gray areas, as there are with all regulation that is we've spent countless hours trying to understand. >> thanks. time has expired. we have a 9/11 memorial service at 10:30. i know some of us are trying to get to. you're recognized. i'll apologize for cutting you off. >> thank you, mr. chairman. i want to thank congressman kennedy and congressman green and all of my colleagues for continuing to focus on mental health parody for our neighbors back home, and thank you to the witnesses. there have been many significant changes to mental health parody. substance abuse parody over the past decade, and as a legislator it's important to know what's happening in the real world. >> your organization health law advocates represent massachusetts residents in he
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mental health and substance abuse disorder parody cases. you also communicate with other advocacy groups across the country that are engaged in similar work. based upon your experience, what is the most common type of potential parody violation you encounter, or are there a few different ones? >> thank you for the question. there's no question, as i said, that among the people we represent mental health and substance ause care is harder to access than other care. that's the experience that's communicated to us by other advocates and providers out across the country. the insurance limits that we see most frequently are things like arbitrary limits on things like residential stays for substance abuse disorders. we see -- we've seen several
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patients, for example, who have lost their coverage for residential substance use treatment regardless of their condition after two weeks. it's like a hard stop, and then that's it. then services are stopped. that's something that we see as a significant barrier. the full range of scope of services is also something that we see not being provided to consumers. especially intermediate services, intensive outpatient services. again, residential care and other types of services that aren't acute and aren't outpatient are very common. as i mentioned, we also see unusual limits on medication assisted treatment that seem to be arbitrary and don't necessarily align with what our review of the medical necessity requirements are. those are some -- also -- >> when you raise the issue with insurance providers, typically is it remedied, or is it a
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fight? >> so, you know, it really runs the gambit. when we talk to health plans on behalf of our consumers, sometimes we are able to remedy the problem. we'll be able to provide a certain amount of information or provide some clarity on the situation or an analysis of the pairty law in some cases where we might say we think that this process counters the parody law and the health plan will change its course. >> appeals do result in the overturning of decision that is are made by the health plans. we have a pretty good record, i think. very good record, actually, when insurance denials occur in changing the outcome. >> it's really too bad that folks need an advocate at all because they are dealing with the personal issues every day. thank you for what you are
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doing. congressman kennedy raised the point. my colleague from texas would agree that the fact that the taxes in florida have not exp expanded medicaid at all. do you have an opinion on what medicaid expansion has meant for families and mental health treatment across the country? >> well, i think the medicaid expansion really has provided just incredible financial stability and support for state medicaid programs which enable them to support the -- really the entire range of services that members are entitled to, but specifically mental health and substance use services which are typically and historically short changed. i think it's been just hugely successful in that way. more people are enrolled in insurance, obviously, because of the expansion. people have better coverage.
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i would -- you know, undeniably the expansion has in all sorts of different ways helped people throughout the country access mental health and substance use services. >> i hope they hear that back home in the state capital. the most important thing would be for the state of florida to expand medicaid. thank you very much. i yield back. >> thank you. i recognize mr. -- from new mexico for five minutes. >> thank you very much, mr. chairman. i'm co-sponsor of congressman kennedy's legislation and applaud all the work that congressman kennedy is doing in this space to continue much of the work that has been done by the kennedy family in carrying on with the work that was done by both senator paul wellstone and senator pete -- senior senator from my home state of new mexico. in new mexico right now we have an issue before us where the state of new mexico under
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governor susannah martinez unnecessarily suspended payments to 15 behavioral health providers claiming fraud, and the system was thrown into chaos. now even though every provider has been exonerated by the attorney general of the state of new mexico, many of these providers have been forced to close their doors, and we all know who was left out. it was the patients. it was the people who needed help the most. mr. selig, can you talk to us about what's such a disruption means for someone struggling with mental health issues if their provider is suddenly -- the trust that's established to get back in that door. what does that mean to someone that is struggling with mental health issues, trying to get the support they need? >> well, that sounds like a very incredible situation, and i'm sorry to hear about that situation in new mexico. we represent, again, a lot of people who have mental health
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services, and when they're denied coverage, their services are interrupted, and we have seen really catastrophic effects for people. their conditions get much worse. someone with an eating disorder, for example, which is a high priority for us, who needs a particular level of treatment is denied that level of treatment and is only provided access to a much lower level of care, really their life will be in danger, and that person is really gravely at risk. also, there is absolutely a connection between lack of addressing mental health and substance use services and deterioration of other health conditions, so when people are getting mental health services, other health conditions will suffer too. people aren't as able to attend to situations like perhaps heart disease or diabetes. really there's a cascading affect when people aren't able to access mental health and substance use care that i think is really life-threatening and disruptive.
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you know, nto their lives and livelihoods for sure. >> along the same line that congresswoman caster was asking congressman green to put on the table concerning states that did not have medicaid expansion. in new mexico right now what we're seeing is the state recently made a decision to cut provider medicaid reimbursement by $400 million. especially with the shake of the mental health system, we have grave concerns, and we're looking for some support. specific to the reimbursement rates, mr. selig, is a low reimbursement for behavior health providers an impediment to insuring robust access, and how can we encourage behavior of health providers in the medicaid program. >> i think there's no question. i mean, that's what we hear from providers. they would love to be able to provide the services being reimbursed. i think the rates are an important factor. along side the other -- going
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back to the rates, i think that it's absolutely connected to the inability of consumers to access providers because they're not the network because providers choose not to accept insurance because of low reimbursement rates. in massachusetts we've recently been able to increase actually reimbursement rates for outpatient providers. we really applaud our state government for doing that. i think there's more work to do in that area, but that has been very well received by the provider community in massachusetts, and i think it's going to have some impact going forward. we would encourage other states to do the same. >> appreciate that. mr. selig, the other question i have for you, you actually addressed which was the impact to someone's physical health if if they're not able to get the mental health care that they need, and you described exactly that impact. i appreciate you addressing that. mr. chairman, you know, while i
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hope that the committee and the congress will move forward to support congressman kennedy's legislati legislation. >> thank you. recognized for five minutes. >> thank you, mr. chairman. thank you all for your testimony. >> for along we've looked at
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mental health as totally separate from physical health. the previous speaker just said -- the questioner just made that point, but i want to go into it because we know the two are so intrinsically linked. we need to insure that our public policy recognizes the important fact that if we ever really want to help our nation become more healthy and productive, this -- a topic needs to be addressed. i'm proud of the work that congress has done over the years as parody between the behavioral health and physical health services. i want to be clear. we've come a long way. i believe we've missed an opportunity to take the next necessary steps to address this issue in mental health
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legislation. we considered here in this committee earlier this year. today's hearing is a chance to reinvigorate this conversation, help guide this committee to do what is necessary to insure that individuals get the care they need when they need it. mr. selig, i know you have been -- you see the shortcomings in this current system so well. while we know that these issues affect all in need in one way or another, i wonder if you would speak a minute about the compounding affects on more vulnerable and serve -- underserved populations like children. it's estimated that at least in your experience, how does the lack of coverage -- this lack of coverage affect children? are there any unique access issues faced by children?
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you mentioned eating disorders, and that's just one. is there a difference for children in medicaid and chdp and those with private insurance? >> well, thank you for raising that, and particularly for highlighting the needs of children. there's no higher priority for our organization than trying to access mental health and substance use services for children. we do see specific types of services that are harder -- that children have difficulty accessing. i mentioned a couple of them. children with autism. difficult to access especially. applied behavioral analysis services. eating disorders you mentioned. another. there are also, i would mention, many children supplely there's a long wait for services. authorization for coverage may be in place, but -- this particularly speaks to children on medicaid in our state. there can be lengthy waits for
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services, and i think that also connects to the issue of the availability of providers. i would say that, you know, children as much as any other population are impacted by this kind of thing. they have very special needs. they see different providers than other people, obviously. their needs are complex, and they're intermingled with family concerns. we're very cognizant of the needs of children and pay very close attention to them. >> thank you. >> i so agree. i notice many of the years i worked as a school nurse. having a child on a waiting list is -- in congress in so many ways because they change so dramatically over the month. sometimes it's years. by the time they can be treated and seen, those symptoms they
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have have exacerbated and become so much worse. the impact is so much more than their health. it affects their education, their ability to learn and work. it sets them on a pathway that's destructive. not opportunity. challenging. it's very clear that barriers to getting the care they need is not only harmful for the child, but they really impact our society as a whole. the whole family is affected by it. it is really an urgency, and that's why we have to make sure that these services become more available. again, i want to salute my colleague, joe kennedy, and pledge my support for making sure this topic stays on the table and that it actually goes somewhere further. thank you very much. i am yielding back. >> i want to thank mr. kennedy and chairman upton for working together to make this come together. i thank the witnesses for being here. i think that concludes all of our questions. >> i'll take a look if i have time. >> well, no.
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the 9/11 memorial is coming. ten business days to submit questions for the record, and ask the witnesses to respond. members to submit the questions by the close of business on friday, september 23rd. you have an opportunity to submit more questions. mr. kennedy. the subcommittee stands adjourned. thank you.
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>> how do you see that going? >> hopefully well. >> how many conversation with them? >> i think if one of the important pieces of this hearing i think from -- was a recognition from witnesses, again, bipartisan, that this is an important part of refortunately of the system. and -- many of them are.
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>> children for themselves. i think there is a recognition that more needs to be done. i hope that as companies get familiar with the importance of parody and then, again, what this legislation actually does in terms of not adding additional regulation and to make sure that folks will come -- >> are there -- in the senate looking to when it comes to their -- >> you know, senator warren has filed companion legislation in the senate. senator powell -- you know, i think there has been the support that this legislation has gotten. it's submitted in the record. patient groups and advocates. to recognize, again, there's --
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patients are getting access. insurance companies aren't that compliant with existing federal laws. it's an important part to the system. i can't speak with details to the process going forward, and senator chris murphy's bill. hopefully it's something that -- if not again we'll push for something, a bill to get through. >> what issues did you want to discuss farther with the panel that you didn't get to talk about today? >> a couple. i think parody is a critically important piece to this. i would love to be able to talk about that. i'm more specific about some of the details of the specifics of the legislation and understanding that her members are doing their best to comply with the law. what continues to be that. if they are supportive of other parts to it and get support that will be a big help. i also think that a proposal
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like this would be important. we heard issues around reimbursement, and so i think we'll continue discussions as well. >> where do you see this going in the next few months as we close out the year? >> again, i think today was an important step forward. hopefully they found it as informative as i did, and we'll certainly go back with them about discussions going forward, and, again, part of this depends on what happens with the senate, and if a bill doesn't make it out of the senate, we have to start all over again in january. i think there had been a consistent message from our side of the subcommittee that even with the proper under congressman murphy's bill that it's an important step forward, and it's a first step forward. regardless of whether that bill gets passed or not, reforms around parody, reforms around reimbursement rates, reforms around work force shortages, all
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have to be addressed, and those are systemic reforms to our mental health care system that you're not going to -- i don't think are just adequately -- the reauthorization of programs. >> on that point, again, you know, that's -- when you listen to these witnesses talk and when you talk to advocates they say those are the three things that need to be addressed, and those really aren't addressed in the mental health package that was passed by the house. do you think -- i mean, would you find the bill effective? >> i think it's an important step forward. look, there are some good things in there, and it does make some progress. you have to give credit where credit is due, and i think we see congressman murphy for -- that being said, we've git's no comprehensive overall fix. i think they've indicated that. there's systemic challenges with the way that that system works. if you look at that, i think you start to dive into those and whether they're -- that system
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is funded privately from our insurance, parody needs to be enforced so that there's actually an investment made in investment and treatment rather than triage. the safety of our mental health system ends up -- we saw it in the court system all the time. that's not the way that our society should treatment mental illness by locking people up. it has to address the private side -- excuse me, the public side, which is medicine kads. when you have medicaid reimbursement rates that are dismal, such that psychiatrists and social workers, they have mortgages and loans. they've got their own pressures as well. when you are looking at those average salaries and work force shortages, if medicaid is only paying you pennies on the dollar to see a poor patient, many of them -- the economic incentives are the ones that you see. you see doctors, look, we'll take cash only. we have such a shortage of doctors. you have such an overwhelming majority of patients that have
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need that they can turn down patients. they're economically incentiveized incentive i incentiveized to do so. we heard issues around problems like student loans and programs that were brought up. parody is a critical piece of this. >> what do you think of secretary clinton's plan? >> i thought it was great. particularly the part that they parodied from our bill. that was great too. look, i give an awful lot of credit to the secretary for her attention to this and that stems back from the time that she spe spent. >> there's an opiate problem that has affected so many families. people that are trying to get
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access to treatment that they haven't been able to. i applaud her efforts for it. >> thank you. >> thanks, guys. >> we want to thank you for your time. >> thank you. >> great. >> thank you for your leadership as a psychiatric social leader. it's really important. >> yeah. >> there's another issue we need help with. >> that has to deal with --
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>> c-span's washington jushl live every day with news and policy issues that impact you. and coming up saturday morning washington examiner commentary writer ash skal and zoe carpenter will join us to talk about the latest campaign 2016 developments where are then anthony from the center for strategic and international studies will take about the united states recent $is.3 billion in payments to iran to settle an unresolved arms deal. >> join the discussion.
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>> this weekend on american history tv, we look back 15 years to the september 11th terrorist attacks through stories of americans who are at the white house, the u.s. capitol, the pentagon, and in the skies above washington d.c. on saturday at noon eastern we'll hear from john jester, says former chief of the pentagon defense protective service, mary beth cahill, former chief of staff to senator edward kennedy, and mary madeline, former aid. >> we knew this was not an accident. it was some kind of act of terror. >> and on sunday u.s. navy admiral david thomas, former senate majority leader daschle,
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former white house chief usher, and major heather penny, f-16 pilot at the district of columbia air national guard. >> the aircraft flight 93 is not in the near vicinity and able to prosecute an attack at that point of time. we need to get back and make sure that we can play the short goalie game now that we cleared out the space. when we returned back to d.c., that was when things began to -- i mean, on one hand settle down because we never, you know -- flight 93 wasn't there, and as we discovered, you know -- as we discovered later, the passengers on that flight were truly heroes. actions prevented four al qaeda hijackers on september 11, 2001, from crashing their plane into
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its likely target, the u.s. capitol building. >> flight 93 national memorial represents a lot about what makes america a fantastic country. on september 1 1th, 2001, the people that were on board flight 93 were every day, ordinary people. citizens of the globe even. it shows you can make a difference no matter how big or huh small and no matter where you are at. >> for our complete american history schedule, go to >> sunday is the anniversary of the 9/11 attacks. the atlantic magazine hosted a series of conversations about
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how national security has changed in the past 15 years. this first panel includes former homeland security secretaries jay johnson and tom ridge and former senator joe lieberman. it's two hours. >> good morning, everybody. welcome. i'm so glad to see supper a packed house. as we all know, this sunday is the 15th anniversary of a day that has been seared into our collective memories. on september 11th, 2001, 19 al qaeda militants hijacked four jetliners and flew two of the planes into the world trade center, the third plane crashed into the pentagon, the fourth in a field in western pennsylvania 80 miles from pittsburgh. i think we all know that sequence by heart. the attacks that shocked the world. we're here to mark that day 15 years later and to ask ourselves
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the question. are we any safer today than we were then? our inspiration for this morning comes from this month's cover story by journalist steven brill. he is here with us this morning. he spent a year investigating the $1 trillion spent by the government to defend against terrorist attacks. before we dive into our state of national security and the cost of protecting the nation, we also want to acknowledge the profound loss that occurred on that beautiful september morning. here's the story of two of them. ♪ ♪
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>> there were a couple of days each year you were allowed take your children to work, and joe loved it. that was his birthday present. that he would spend the night. we would have a cake, and the guys that i work with, they would take a milk container, and they would cut out the facsimile of a building, and they would put it on the top of the cake, and then they would light it up, and they would tell joe to put it out, and he would throw a pot of water on it. the birthday cake was a little soggy, but this is what he wanted. joe started dating a young lady whose father was a police officer, and he came home one day and said i'm taking a police test. i says, joe, you're only 17 years old.
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he said, ah, no big deal. on the other side of the roomie son, john, wanted to be the next donald trump. he was going to make a million dollars and take care of his mother and father. but in 1984 he came down with throat cancer. he noticed then how my unit took care of us, and he says i'm going to become a fireman. i said you're kidding me. firemen don't make millions of dollars. i'm not going to live like a king. i was very happy. very proud. my father had been on the fire department, and he was the first one to be issued badge number 3436, and they reissued it to my son john. the badge was only used by two. both the boys would call me when they were working. john would always call around 3:30, 4:00, and that particular night, september 10th, we spoke for a few minutes, and i says, i love you. he says i love you.
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joe called me in the morning and told me to turn on the television, this is a plane just hit the trade center. he said i'm heading south on west street. this is a big one. i just said be careful. i love you. i love you too. that was it. we had the boys for -- john for 36 years and joe for 34 years. ironically badge number 3436. i don't have any could have, should have, or would have's. i wouldn't have changed anything. there's not many people that the last words they said to their son or daughter anything. that's not many last words they say to their sons or daughters that i love you. so that makes me sleep at night. ♪
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all right, thanks story core for that piece. record our one story on 9/11. i want to thank hamilton for their under writing support. they made this morning possible. thank you very much to them. before we begin, a few notes. we are on twitter. you can use the #atlanticsafer. >> with that, lets begin of our secretary. the current secretary of
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homeland security, jeh johnson here to lead our congress. [ applause ] here to lead the conversation is steven bill. steven, take it away. >> thank you. with that said, notice our introduction, i will direct the question to you, i will call you governor and him secretary so we know who we are talking about. >> i will answer to both. >> on september 11, you did answer to the governor and you left your job in a matter of days and taking a job in washington, you did not have a home except the governor's mansion. you had no idea what the yob was about a was -- the job was about and the
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salary. those were days when people did things right after 9/11. knowing what you know now, i don't know in secretary johnson did this but lets make believe that he did. the day he got appointed and if he had called you and asked you for advice and said you know, what's the one thing that i really need to know about this job that's not obvious. what's the one thing i need to watch out for. what would you or did you tell them? >> first of all, steven, let me thank you forgiving me the opportunity to participate. it is an important forum and i thank you for that. >> first of all, you should know that the secretary did call. the first thing i told the secretary johnson that there is only two people in town that know how tough your job is and how it is going to be. you are truly my two successors. >> i don't recall the specifics of it.
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i did recall general economy of how important it is for him to upgrade the moral of the enterprise and there has been multiple vacancies and difficult to lead the organization when you have key people in the organization and slots to be filled and gaps personnel and at the highest levels and warning him of the challenges of dealing with hundreds plus agencies and committees and subcommittees. what i have said to him is secretary, as i started this conversation, you have a tough job. nobody in town knows how tough it is and call me if you can help. what would you, secretary johnson, tell your successor whether it is a successor appointed by hillary clinton or donald trump as we know that's going to be -- he knows
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everything anyway. what would you tell your successor. >> steve, first of all, thank you for your journalism and the work you put into the article this month. i know you spent a lot of time on it. i thought, it was very, very helpful. my message to my successor will be several. one is the nature of our business and homeland security is you are always on defense and in our world and tom knows this. good news is no news. if there is a successful national political convention from the security standpoint or successful un general assembly or successful visit by the
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president to the far east, it is the result of a lot of hard work and professionalism by who works from us. that does not get reported. bad news is front page news. the good news in homeland security is often no news. one of the things this we continually have to is to make sure that our people are recognized for the work that they do on defense, protecting home hand and the american people and protecting their leaders and cyber space. continually thank them and stress the good work they do and recognize it and projected to the american public whether it is aviation or ports security or cyber security. my other management is continue our work that we have gone through management. through the initiative that i started a little over two years
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a ago, we have done a lot to make the department an effective place. we need to work with congress to get them to embrace some of my unity of efforts of initiatives. you don't have to call the unity of efforts. that was my emblem. there is some things in congress right now that improves the way the department does business. and so that work needs to be continued. that needs to be priority one in addition to the general work of the homeland. >> let me ask you this, this is a hard question. governor, how many terrorist attack that you think we'll suffer in the united states in the next year. >> what type? >> how many? what's your guess? >> well, i think, i am not going
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to speculate the number. we need to accept the reality that the threat surface has changed and the number of actors have increased and the number of profiles are significantly different than it was on 9/11. there is an evidentablety. there is a variety of means where they can inflict their damage and affect the physic of the country. the mass shootings. i think we should not -- i think we should accept tit.
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what the country needs to do is accept the reality that will probably happen again, you have no idea how many times and there is no way to predict but put in to context of everything else that happens to impact our lives in a negative way in this country. 400 to 500 people die over labor day. they got in their automobile on friday morning and did not go home to their loved ones on monday. i am not trying to say the pain and suffering, is not significant or real. it is. i want america to die down of the hyperbole, lets reflect the past 15 years. we are safer now than we have ever been. there are still gaps. lets close it and lets accept
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it. don't change of what we do because we are fearful of another attack. >> you sound like president obama. >> he said -- >> i won't go that far but okay. >> let me take a shot at it. he was quoted in atlanta interviewed by jeff goldberg that he wishes america would have adopted that perspective and he was immediately attacked by republicans in essence for throwing in the talent. >> are you throwing it in? >> no. listen, to that extent, i will associate myself with the president's observation that we accept the reality. nobody likes it. we don't want to accept it, but it is a global scourge so lets not be breathe less about it. with all respect to all the journalists and the media of the
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coverage, there is more coverage on that isolated attack that goes for days and days and there is of the automobile accidents and the 600 or 700 people killed in the major urban areas because of gun violence. it is painful and affects us. lets try to put it in perspective. if that's what he says, i think he's right on that issue. >> what's your number, two, our four four or six or two? >> what constitute the attack verses 15 years ago? >> someone of an assault weapon. >> if you are asking how many san bernardino or orlando type of attacks will we have in the year 2017, no natural expert or security is going to be in a


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